Council Tax Financial Questionnaire

You are being asked to provide a clear, complete, and accurate picture of your current and recent financial situation for your request to repay your Council Tax arrears.

You must include details of anyone who also shares financial responsibility with you.

Council Tax details

Is your Council Tax reference an 8 or 11 digit number?(Required)

8 digit reference number

11 digit reference number

Please enter your 8 digit council tax reference number(Required)

Please enter your 11 digit council tax reference number(Required)

Are you completing this form for yourself?(Required)

Yes

No, I am making the referral on behalf of someone

My details

My details (as the referrer)

Title(Required)

If other, please specify title(Required)

First name(Required)

Last name(Required)

Other names

My contact details

My contact details (as the referrer)

Contact telephone number(Required)

Alternative contact number

Enter email(Required)

What is your relationship to the person being referred?(Required)

Carer

Family/friend

Redbridge Council staff

Other ...

if other, please specify(Required)

Details of person being referred

Title of person being referred(Required)

If other, please specify title(Required)

First name of person being referred(Required)

Last name of person being referred(Required)

Other names of person being referred

Contact details of person being referred

Contact telephone number of person being referred(Required)

Alternative contact number of person being referred

Enter email address of person being referred(Required)

Address details

Address details of person being referred

Do you live in Redbridge ?(Required)

Yes

Does the person being referred live in Redbridge ?(Required)

Yes

Enter postcode(Required)

Find addressSelected address

Enter postcode of person being referred(Required)

Find addressSelected address

Address(Required)

Address Line 1 Address Line 2 Town or City County Postcode

Address of person being referred(Required)

Address Line 1 Address Line 2 Town or City County Postcode

Marital status(Required)

Single

Married

Partner

Separated

Divorced

Widowed

Marital status of person being referred(Required)

Single

Married

Partner

Separated

Divorced

Widowed

Spouse/Partner details

Title(Required)

If other, please specify title(Required)

First name(Required)

Last name(Required)

Other names

Spouse/Partner contact details

Contact telephone number(Required)

Alternative contact number

Enter email address

Employment details

Are you currently in employment?(Required)

Yes

Is the person being referred currently in employment?(Required)

Yes

Are you self employed?(Required)

Yes

Is the person being referred self employed?(Required)

Yes

Your self employment details

Self employment details of person being referred

Name of business(Required)

Type of business(Required)

Business address(Required)

Address Line 1 Address Line 2 Town or City County Postcode

Telephone number(Required)

Employer details for person being referred

Your employer details

Name of employer(Required)

Employers address

Address Line 1 Address Line 2 Town or City County Postcode

Telephone number(Required)

Spouse/Partner employment details

Is your spouse/partner currently in employment ?(Required)

Yes

Is the spouse/partner of the person being referred currently in employment ?(Required)

Yes

Is your spouse/partner self-employed?(Required)

Yes

Is the spouse/partner of the person being referred self-employed?(Required)

Yes

Your spouse/partners self employment details

Spouse/Partner of person being referred self employment details

Name of business(Required)

Type of business(Required)

Business address(Required)

Address Line 1 Address Line 2 Town or City County Postcode

Telephone number(Required)

Spouse/Partner of person being referred employer details

Your spouse/partners employer details

Name of the employer(Required)

Employer's address

Address Line 1 Address Line 2 Town or City County Postcode

Telephone number(Required)

Property details

Do you own the property that you are residing in?(Required)

Yes

Does the person being referred own the property that they are residing in?(Required)

Yes

Is the property jointly owned?(Required)

Yes

Name of joint owner

Telephone number

Other property details

Do you own/jointly own any other properties (including any overseas)?(Required)

Yes

Does the person being referred own/jointly own any other properties (including any overseas)?(Required)

Yes

Is your other property in Redbridge?(Required)

Yes

Enter postcode(Required)

Find addressSelected address

Address of other property owned(Required)

Household details

Please list all the people who live in the home of the person being referred

Name	Date of birth	Relationship (e.g. son, daughter)	Actions

There are no Entries.

Maximum number of entries reached.

Please list all the people who live in your home (other than you)

Name	Date of birth	Relationship (e.g. son, daughter)	Actions

There are no Entries.

Maximum number of entries reached.

Please list all the people who live in your home?

Do not list yourself or your spouse/partner

Name	Date of birth	Relationship (e.g. son, daughter)	Actions

There are no Entries.

Maximum number of entries reached.

Please list all the people who live in the home of the person being referred ?

Do not list the person being referred or their spouse/partner

Name	Date of birth	Relationship (e.g. son, daughter)	Actions

There are no Entries.

Maximum number of entries reached.

Your monthly income and benefits

Monthly income and benefits of person being referred

Salary and wages amount?

Universal Credit

Income Support

Working Tax Credit

Child Tax Credit

Child Benefit

Sick Pay

Disability benefit

Carers Allowance

Council Tax support

Private pension

Rental/Board

Local Housing Allowance/Housing Benefit

Other benefits/tax credits (e.g.maternity benefits (MN)

Employment and Support Allowance or Statutory

Jobseekers Allowance (income based)

Jobseekers Allowance (contribution based)

Grants/Loans/Bursaries

Other income

Your spouse/partners monthly income and benefits

Spouse/Partner of person being referred monthly income and benefits

Salary and wages

Universal credit

Income Support

Working Tax Credit

Child Tax Credit

Child Benefit

Sick Pay

Disability benefit

Carers Allowance

Council Tax Support

Private pension

Rental/Board

Local Housing Allowance/Housing Benefit

Other benefits/tax credits (e.g.maternity benefits (MN)

Employment and Support Allowance or Statutory

Jobseekers Allowance (income based)

Jobseekers Allowance (contribution based)

Grants/Loans/Bursaries

Other income

Your monthly expenditure

Monthly expenditure of person being referred

Mortgage

Rent

Service charges

Credit cards

Secured loans

Council Tax

Mobile

Water

Gas/Electric

Telephones

Satellite/Cable

TV/Licence

Child care costs

Car insurance

Road tax

Fuel

Internet

Life insurance

Child Maintenance

Unsecured loans

Household shopping

Public Transport fares

Buildings/Contents insurance

Any other expenditure

Your spouse/partners monthly expenditure

Spouse/Partner of person bening referred monthly expenditure

Mortgage

Rent

Service charges

Credit cards

Secured loans

Council Tax

Mobile

Water

Gas/Electric

Telephones

Satellite/Cable

TV/Licence

Child care costs

Car insurance

Road tax

Fuel

Internet

Life insurance

Child Maintenance

Buildings/Contents insurance

Unsecured loans

Public Transport fares

Household shopping

Any other expenditure

Monthly instalment payment offer

What is your offer of a monthly instalment payment?(Required)

What does the person being referred want to offer as a monthly instalment payment?(Required)

Your offer is not guaranteed as being accepted and any offer agreed is also subject to periodic reviews.

Written confirmation of agreement will be either e-mailed or posted within 14 days of being received.

You should make some form of payment whilst your request is being dealt with.

The offer is not guaranteed as being accepted and any offer agreed is also subject to periodic reviews.

Written confirmation of agreement will be either e-mailed or posted within 14 days of being received.

Some form of payment should be made whilst the request is being dealt with.

Declaration(Required)

I confirm that I have read each question to the claimant and recorded the answers given by them. As far as I know, they are true and complete.

I understand and agree to the above statement

Declaration(Required)

I confirm that the information I have given is complete and accurate to the best of my knowledge. I understand that the Council may check the information against other data sources and that the option to pay by instalments may be withdrawn if I knowingly supply false information.

I understand and agree to the above statement